Self-Reported Hypertension and Use of Antihypertensive Medication Among Adults — United States, 2005–2009

Hypertension affects one third of adults in the United States and is a major risk factor for heart disease and stroke. A previous report found differences in the prevalence of hypertension among racial/ethnic populations in the United States; blacks had a higher prevalence of hypertension, and Hispanics had the lowest use of antihypertensive medication. Recent variations in geographic differences in hypertension prevalence in the United States are less well known. To assess state-level trends in self-reported hypertension and treatment among U.S. adults, CDC analyzed 2005-2009 data from the Behavioral Risk Factor Surveillance System (BRFSS). The results indicated wide variation among states in the prevalence of self-reported diagnosed hypertension and use of antihypertensive medications. In 2009, the age-adjusted prevalence of self-reported hypertension ranged from 20.9% in Minnesota to 35.9% in Mississippi. The proportion reporting use of antihypertensive medications among those who reported hypertension ranged from 52.3% in California to 74.1% in Tennessee. From 2005 to 2009, nearly all states had an increased prevalence of self-reported hypertension, with percentage-point increases ranging from 0.2 for Virginia (from 26.9% to 27.1%) to 7.0 for Kentucky (from 27.5% to 34.5%). Overall, from 2005 to 2009, the prevalence of self-reported hypertension among U.S. adults increased from 25.8% to 28.3%. Among those reporting hypertension, the proportion using antihypertensive medications increased from 61.1% to 62.6%. Increased knowledge of the differences in self-reported prevalence of hypertension and use of antihypertensive medications by state can help in guiding programs to prevent heart disease, stroke, and other complications of uncontrolled hypertension, including those conducted by state and local public health agencies and health-care providers.

for Kentucky (from 27.5% to 34.5%). Overall, from 2005 to 2009, the prevalence of self-reported hypertension among U.S. adults increased from 25.8% to 28.3%. Among those reporting hypertension, the proportion using antihypertensive medications increased from 61.1% to 62.6%. Increased knowledge of the differences in self-reported prevalence of hypertension and use of antihypertensive medications by state can help in guiding programs to prevent heart disease, stroke, and other complications of uncontrolled hypertension, including those conducted by state and local public health agencies and healthcare providers.
BRFSS is a state-based telephone survey of health behaviors among adults aged ≥18 years.* The survey has been conducted by state health departments, with assistance from CDC, since 1984. Questions on hypertension are asked in odd-numbered years. Since 2005, two questions about hypertension have been included in BRFSS. The first question is, "Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?" Respondents who answer "yes" to the first question are then asked, "Are you currently taking medicine for your high blood pressure?" These questions were used to assess prevalence of self-reported hypertension and proportion reporting antihypertensive medication use among those with reported hypertension in 2005, 2007, and 2009. Estimates were calculated for the United States overall and for the 50 states and the District of Columbia. In addition to analysis by state, estimates were analyzed by age group, sex, race/ ethnicity, † and level of education. Age-adjusted estimates were calculated using the 2000 U.S. standard population. Linear trends were assessed using orthogonal polynomial coefficients, and results were considered significant at p<0. 05 those with selfreported hypertension, the proportion reporting current use of antihypertensive medication was highest in Tennessee (74.1%) and lowest in California (52.3%); however, Tennessee showed no significant change in reported antihypertensive medication use from 2005 to 2009, whereas California had a significant increase, from 48.0% to 52.3%. As with self-reported hypertension, the proportion of participants reporting use of antihypertensive medication generally was higher in southern states and lower in western states ( Figure). States that showed significant increases in use of antihypertensive medications included California, Iowa, and Michigan, whereas Kentucky, Nebraska, and Rhode Island had significant decreases.

Editorial Note
The findings in this report, using BRFSS data, indicate that from 2005 to 2009, a small but significant increase in the prevalence of self-reported hypertension was observed among U.S. adults. Among those with self-reported hypertension, the proportion who reported use of antihypertensive medication also increased significantly.
In 2011, a report based on results from the National Health and Nutrition Examination Survey (NHANES) showed that among adults aged ≥18 years, the prevalence of measured hypertension did not increase significantly from 1999-2002 to 2005-2008; however, the use of antihypertensive medication and control of hypertension showed significant increases (1). The prevalence of measured hypertension in NHANES did not increase during 1999-2008 (1); therefore, the increase in self-reported hypertension described in the current report likely is related to an increase in the awareness of hypertension. Measured blood pressure is not available with BRFSS surveys; therefore, hypertension control could not be assessed in the current report. The findings in this report show that among persons with hypertension, the proportion reporting antihypertensive medication use increased overall from 2005 to 2009; however, only a few states showed significant increases or decreases in the proportion reporting antihypertensive medication use. Substantial differences among states were observed for selfreported hypertension prevalence, in general, the prevalence was higher in southern states than in other regions. Use of antihypertensive medication varied by state, but overall BRFSS estimates generally were consistent with other national estimates (5-7). The recent REasons for Geographic and Racial Differences in Stroke (REGARDS) study found that, compared with whites, black participants were more aware of hypertension and more likely to be treated. However, among those treated, blacks were less likely than whites to have their blood pressure controlled (5). The high prevalence of hypertension in the southern states found in this study is in the "stroke belt," a geographically identified region of high stroke morbidity and mortality, and likely is contributing to the disparate burden of disease in the region (8). The findings by sex were similar to results from NHANES 2005-2008, which found that antihypertensive treatment was lower among men than women (7). What is already known on this topic?

FIGURE. Age-adjusted prevalence of self-reported hypertension among adults and the proportion of those participants reporting use of antihypertensive medication, by state -Behavioral Risk
Hypertension is a major risk factor for cardiovascular disease. In the United States, hypertension affects approximately one third of the adult population. Differences in prevalence of hypertension and use of antihypertensive medications exist among states and sociodemographic subgroups. As with this report, U.S. states and territories frequently use Behavioral Risk Factor Surveillance System data to aid in tracking priority health conditions and behaviors and to support the targeting of limited programmatic resources to high-prevalence areas.
What is added by this report?
From 2005 to 2009, the prevalence of self-reported hypertension among U.S. adults increased from 25.8% to 28.3%. Among those with self-reported hypertension, use of antihypertensive medications increased from 61.1% to 62.6%. Among states, rates of self-reported hypertension in 2009 ranged from 20.9% to 35.9%.
What are the implications for public health practice?
Improving hypertension awareness and initiating appropriate treatment are important to increase blood pressure control and reduce risk for heart disease and stroke. The findings in this study provide public health practitioners information to help target blood pressure control efforts. Public health officials, particularly in those states with a high prevalence of hypertension, should consider a coordinated and multifactorial approach to blood pressure control with focused attention in areas including sodium reduction, health systems strategies such as promotion of the collection and use of quality measures, promotion of team-based care, and community-clinical linkages.
hypertension through participation in healthy lifestyle behaviors, and using appropriate and specific antihypertensives medications with integrated clinical systems to support sustained adherence (2). A CDC goal is to increase public health interventions in clinical and community settings to reduce the deleterious effects of hypertension by increasing awareness and control of high blood pressure. § One effective intervention is the Community Preventive Services Task Force recommendation for use of team-based care to improve blood pressure control. ¶ Currently, 41 states receive CDC funding to develop and implement heart disease and stroke prevention programs.** The findings in this report are subject to at least three limitations. First, data were self-reported, and hypertension and use of antihypertensive medications were not verified independently. Second, BRFSS surveys only noninstitutionalized persons with landline telephones; in 2009, 24.5% of U.S. households only had cellular telephone service (9). Finally, median state response rates for BRFSS were low; however, BRFSS provides the only available state-specific estimates of hypertension prevalence and antihypertensive medication use.
Hypertension is a major modifiable risk factor for cardiovascular disease, and improving awareness of hypertension is an important first step to treating and controlling hypertension and preventing heart disease and stroke. Clinical guidelines for hypertension management emphasize the control of § Available at http://www.cdc.gov/dhdsp/programs/nhdsp_program/goals.htm. ¶ Available at http://www.thecommunityguide.org/cvd/teambasedcare.html. ** Information available at http://www.cdc.gov/dhdsp/programs/nhdsp_ program/index.htm. CDC's National Heart Disease and Stroke Prevention Program works to increase prevention and control of high blood pressure through sodium reduction, health system strategies such as collection and use of quality measures, promotion of teambased care, and community-clinical linkages. In addition, the Million Hearts initiative, a public and private partnership co-led by CDC and the Centers for Medicare and Medicare Services, targets blood pressure control and seeks to align and coordinate resources across community and clinical settings (10). Increasing awareness of hypertension, improving hypertension control, and encouraging adherence to evidencebased practices addressing hypertension are needed, especially in those states with higher prevalence of hypertension and lower proportion of use of antihypertensive medications.